patient safety

QSHI Annual Reports | Reports | Safety Links

Reports and Safety Links

QSHI Annual Reports

Reports

Review of Calgary Health Region Emergency & Urgent Care Services – September, 2007.
This review by the Health Quality Council of Alberta (HQCA) was requested by the Region. 11 recommendations resulted, focusing on organizational, department and service level performance to improve the quality and safety of patient care. View Summary.. View Report…

Infection Prevention and Control Report - Vegreville, Alberta - July, 2007.
After a closure of the Central Sterilization Room at Saint Joseph’s General Hospital in Vegreville, the Health Quality Council of Alberta (HQCA) conducted a review of underlying causes and contributing factors. 76 recommendations to improve system safety and quality with a focus on infection prevention and control throughout the healthcare system were made. View Report…

Fluorouracil Incident Root Cause Analysis – Edmonton, Alberta – April, 2007.
System failures caused a fatal overdose of fluorouracil in a cancer patent. Systemic issues have been identified and the analysis outlines ways to reduce the likelihood of a re-occurrence of this type of adverse event. View Report…

Event Analysis Report: Hydromorphone/Morphine Event – Red Deer, Alberta - November, 2004.
After a fatal switch of narcotics, the Institute for Safe Medication Practices (ISMP ) Canada conducted this review. Recommendations to promote a culture of safety are applicable both locally and worldwide. View Report…

Internal Patient Safety Task Group Report One - October, 2004.
The first internal review of safety practices after the potassium chloride tragedies in the Calgary Health Region. The report identifies and advises leadership on safety concerns, provides recommendations and proposes a long-term strategy in conjunction with the Robson Report. View Report…

Safe Handling of Potassium Chloride Review - July, 2004.
Resulting from a review of international and national best practices for handling potassium chloride, the Health Quality Council of Alberta (HQCA), released several recommendations on safe handling and preparation of the product. View Report…

External Patient Safety Review (Robson Report) - June, 2004.
Stemming from the tragedies at the Calgary Health Region, this external review examines safety practices within the Region and made 121 recommendations to improve safety- 92 which have been implemented so far. View Report… (view highlights to date)

Canadian Adverse Events Study - May, 2004.
This national study of adverse events is a comprehensive source of data. The first Canadian report to provide a national estimate of incidence and frequency of adverse events. View Report…

To Err is Human: Building a safer health system - September, 1999.
The Quality of Health Care in America Committee of the Institute of Medicine (IOM) conducted this report, producing a comprehensive strategy to prevent health-care errors that cause patient harm. The IOM report concluded that errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them. View Report…

patient safety

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Patient Safety Home Initiatives Policies Reports and Safety Links Patient Relations Patient/Family Safety Council Halifax 9 Symposium QSHI Website	patient safety QSHI Annual Reports \| Reports \| Safety Links Reports and Safety Links QSHI Annual Reports QSHI 2007 (pdf) QSHI 2006 (pdf) Reports Review of Calgary Health Region Emergency & Urgent Care Services – September, 2007. This review by the Health Quality Council of Alberta (HQCA) was requested by the Region. 11 recommendations resulted, focusing on organizational, department and service level performance to improve the quality and safety of patient care. View Summary.. View Report… Infection Prevention and Control Report - Vegreville, Alberta - July, 2007. After a closure of the Central Sterilization Room at Saint Joseph’s General Hospital in Vegreville, the Health Quality Council of Alberta (HQCA) conducted a review of underlying causes and contributing factors. 76 recommendations to improve system safety and quality with a focus on infection prevention and control throughout the healthcare system were made. View Report… Fluorouracil Incident Root Cause Analysis – Edmonton, Alberta – April, 2007. System failures caused a fatal overdose of fluorouracil in a cancer patent. Systemic issues have been identified and the analysis outlines ways to reduce the likelihood of a re-occurrence of this type of adverse event. View Report… Event Analysis Report: Hydromorphone/Morphine Event – Red Deer, Alberta - November, 2004. After a fatal switch of narcotics, the Institute for Safe Medication Practices (ISMP ) Canada conducted this review. Recommendations to promote a culture of safety are applicable both locally and worldwide. View Report… Internal Patient Safety Task Group Report One - October, 2004. The first internal review of safety practices after the potassium chloride tragedies in the Calgary Health Region. The report identifies and advises leadership on safety concerns, provides recommendations and proposes a long-term strategy in conjunction with the Robson Report. View Report… Safe Handling of Potassium Chloride Review - July, 2004. Resulting from a review of international and national best practices for handling potassium chloride, the Health Quality Council of Alberta (HQCA), released several recommendations on safe handling and preparation of the product. View Report… External Patient Safety Review (Robson Report) - June, 2004. Stemming from the tragedies at the Calgary Health Region, this external review examines safety practices within the Region and made 121 recommendations to improve safety- 92 which have been implemented so far. View Report… (view highlights to date) Canadian Adverse Events Study - May, 2004. This national study of adverse events is a comprehensive source of data. The first Canadian report to provide a national estimate of incidence and frequency of adverse events. View Report… To Err is Human: Building a safer health system - September, 1999. The Quality of Health Care in America Committee of the Institute of Medicine (IOM) conducted this report, producing a comprehensive strategy to prevent health-care errors that cause patient harm. The IOM report concluded that errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them. View Report… Safety Links Alberta Health Services - Calgary Area Office of Patient Relations Alberta Health Quality Council of Alberta (HQCA) National Institute for Safe Medication Practices (ISMP) Canada Canadian Council on Health Services Accreditation (CCHSA) Canadian Patient Safety Institute Canadian Institute for Health Information International Australian Council for Safety and Quality in Health Care Australian Patient Safety Foundation Institute for Healthcare Improvement Institute for Safe Medication Practices Minnesota Children's Clinics and Hospital National Centre for Patient Safety National Patient Safety Agency National Patient Safety Foundation Safer Health Care for Kids, American Academy of Pediatrics Victorian Government Health Information Sentinel Event Reporting World Health Organization
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